TN 31 (06-04)
HI 00801.226 Date of Entitlement Based on Self-Dialysis Training
A. Policy - Waiver requirements
The entire qualifying period is waived for the ESRD patient who:
B. Policy - Participation in training
A dialysis patient is considered participating in self-care dialysis training for purposes of waiving the qualifying period if a physician in an approved training facility certifies that:
the patient is participating in (or has already completed) the training program during the normal qualifying period;
self-dialysis is feasible for the patient;
the patient has completed or is expected to complete training successfully and is expected to self-dialyze on a regular basis, on or about a specific date, which may be during the qualifying period or after it ends; and
the certification is based on a consideration of all pertinent medical, psychological, and sociological factors as reflected in the facility's records.
NOTE: Training of family members or close friends of the patient who is a small child or a person with a condition that makes it difficult to self-dialyze, is considered training of the patient.
C. Policy — Evidence of training
1. Form CMS-2728-U3
As explained in HI 00801.233, the CMS-2728-U3, End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration is the primary form used as medical evidence of ESRD and dialysis treatments or transplantation. The blocks on this form relating to self-care training must be filled out (items 38-43). The training certification must be signed by a physician personally familiar with the patient's training, i.e., the facility's director or another physician, including the patient's attending physician.
2. Use of “Listing of Renal Providers DOFA Process (SSA)”
The “Listing of Renal Providers DOFA Process (SSA)” is distributed to all Social Security offices on a regular basis. The listing can also be found on the CMS web site at http://www.cms.hhs.gov/esrdgeneralinformation/02_data.asp. It should be used to verify that the training center is approved for self-dialysis training. Approval for one kind of self-dialysis training is considered to be approval for all types of self-dialysis training.
3. When training information is submitted
The training certification is to be executed and dated only after the patient has either entered in or completed the training program. Unless FO final adjudication is possible, the certification is sent (along with the application and other proofs of R-HI eligibility, if these have not already been forwarded) to ODO for review and adjudication.
If the form has already been submitted without training information to establish current ESRD entitlement and, within the qualifying period the claimant enters into a self-dialysis training program, the facility need only complete a supplemental form containing the identification of the patient (name, HIC/SSN, date of birth, sex) and the self-care certification — “Supplemental” will be written at the top of the form. Otherwise, the entire form (except for transplant information) must be completed.
4. Termination of training
If training is terminated during the qualifying period, or before completion of the training program, the qualifying period cannot be waived.
EXCEPTION: The entire qualifying period will be waived if self-dialysis training is terminated before completion of the course because of the death of the patient and, before death, all conditions for waiver based on participation in self-dialysis training in HI 00801.226A. and B. are met.
If there is any indication that training terminated before the death of the patient for any reason other than the deterioration of health (leading to death), waiver is not granted.